Towards a World Wide Web without digital inequality.

The World Wide Web (WWW) empowers people in developing regions by eradicating illiteracy, supporting women, and generating economic opportunities. However, their reliance on limited bandwidth and low-end phones leaves them with a poorer browsing experience compared to privileged users across the digital divide. To evaluate the extent of this phenomenon, we sent participants to 56 cities to measure the cost of mobile data and the average page load time. We found the cost to be orders of magnitude greater, and the average page load time to be four times slower, in some locations compared to others. Analyzing how popular webpages have changed over the past years suggests that they are increasingly designed with high processing power in mind, effectively leaving the less fortunate users behind. Addressing this digital inequality through new infrastructure takes years to complete and billions of dollars to finance. A more practical solution is to make the webpages more accessible by reducing their size and optimizing their load time. To this end, we developed a solution called Lite-Web and evaluated it in the Gilgit-Baltistan province of Pakistan, demonstrating that it transforms the browsing experience of a Pakistani villager using a low-end phone to almost that of a Dubai resident using a flagship phone. A user study in two high schools in Pakistan confirms that the performance gains come at no expense to the pages' look and functionality. These findings suggest that deploying Lite-Web at scale would constitute a major step toward a WWW without digital inequality.

Understanding Reasons for Cancer Disparities in Italy: A Qualitative Study of Barriers and Needs of Cancer Patients and Healthcare Providers.

BACKGROUND: The second leading cause of death in Italy is cancer. Substantial disparities persist in the level of care and outcomes for cancer patients across various communities, hospitals, and regions in Italy. While substantial progress has been made in medical research and treatment options, these advancements tend to disproportionately benefit the wealthier, better-educated, and more privileged areas and portions of the population. Therefore, the primary aim of the current study is to explore possible reasons for inequalities in access to and utilisation of care from the perspective of cancer patients, who are recipients of these treatments, and healthcare providers, who are responsible for their administration. METHODS: After being recruited through social media platforms, patients' organisations, and hospital websites, cancer patients (n = 22) and healthcare providers (n = 16) from various Italian regions participated in online focus group discussions on disparities in access to and provision of care. Video and audio recordings of the interviews were analysed using Thematic analysis. RESULTS: Among cancer patients, 7 themes were identified, while 6 themes emerged from the healthcare providers highlighting encountered barriers and unmet needs in cancer care. Most of these emerging themes are common to both groups, such as geographical disparities, information deficiencies, and the importance of psycho-oncological support. However, several themes are specific to each group, for instance, cancer patients highlight the financial burden and the poor interactions with healthcare providers, while healthcare providers emphasise the necessity of establishing a stronger specialists' network and integrating clinical practice and research. CONCLUSION: Current findings reveal persistent challenges in cancer care, including long waiting lists and regional disparities, highlighting the need for inclusive healthcare strategies. The value of psycho-oncological support is underscored, as well as the potential of the Internet's use for informational needs, emphasising the imperative for improved awareness and communication to overcome disparities in cancer care.

Technology and health inequities in diabetes care: How do we widen access to underserved populations and utilize technology to improve outcomes for all?

Digital health technologies are being utilized increasingly in the modern management of diabetes. These include tools such as continuous glucose monitoring systems, connected blood glucose monitoring devices, hybrid closed-loop systems, smart insulin pens, telehealth, and smartphone applications (apps). Although many of these technologies have a solid evidence base, from the perspective of a person living with diabetes, there remain multiple barriers preventing their optimal use, creating a digital divide. In this article, we describe many of the origins of these barriers and offer recommendations on widening access to digital health technologies for underserved populations living with diabetes to improve their health outcomes.

The roles of health literacy and social support in the association between smartphone ownership and frailty in older adults: a moderated mediation model.

BACKGROUND: Understanding the role of smartphones to promote the health status of older adults is important in the digital society. Little is known about the effects of having smartphones on physical frailty despite its positive effect on the well-being of older adults. This study aimed to explore the association between smartphone ownership and frailty in community-dwelling older adults and its underlying mechanism. METHODS: We used data from the Korean Frailty and Aging Cohort Study and analyzed 2,469 older adults aged 72-86 years. Frailty, health literacy, and social support were assessed by Fried's frailty phenotype, the Behavioral Risk Factor Surveillance System health literacy module, and the Enhancing Recovery in Coronary Heart Disease (ENRICHD) Social Support Instrument, respectively. The mediation model and moderated mediation model were estimated, where the mediator was health literacy and the moderator was social support, to explore the relationship between smartphone ownership and frailty. RESULTS: Of our study participants, 58.9% owned smartphones, and 10.9% were classified as frail. Smartphone ownership was negatively associated with frailty (ß = -0.623, p < 0.001). Health literacy mediated the relationship between smartphone ownership and frailty (ß = -0.154, boot confidence interval [CI] = - 0.222, - 0.096), and social support moderated the mediation effect (ß = -0.010, Boot CI = - 0.016, - 0.004). CONCLUSIONS: Owning smartphones among older adults could reduce the risk of frailty. Promoting health literacy and social support among older adults with smartphones would be effective to prevent frailty.

Cultural capital, the digital divide, and the health of older adults: a moderated mediation effect test.

BACKGROUND: It is of great practical significance to study the intrinsic relationship between cultural capital, digital divide, cognitive ability, and health of older adults in the dual social context of population aging and the digital era. METHODS: We analyzed data from the 2020 China Family Panel Studies (CFPS) initiated by the China Center for Social Science Surveys at Peking University. Physical health, mental health, and memory health were set as indicators of older adults, and the relationship between cultural capital, digital divide, cognitive ability, and health of older adults was examined by hierarchical regression with moderated mediated effect methods. RESULTS: Improvement in the health of older adults is associated with an increase in the level of cultural capital; cultural capital may bridge the digital divide faced by older adults, which in turn promotes the improvement of the health of older adults; the higher the level of cognitive ability, the stronger the effect of cultural capital on the digital divide, and at the same time, the stronger the mediating effect of the digital divide; cultural capital has a more pronounced effect on the health of older male adults living in the city. CONCLUSIONS: The results of the study show that cultural capital can have a positive impact on the health of older adults, but there is urban-rural heterogeneity and gender heterogeneity, in which the digital divide plays a mediating role, and the enhancement of the cognitive ability of older adults will be conducive to the improvement of their health, so the health of older adults should be promoted by improving the level of their cultural capital and the ability of older adults to use digital technology, thus provide references for the protection of health of older adults.

Learning loss due to school closures during the COVID-19 pandemic.

Suspension of face-to-face instruction in schools during the COVID-19 pandemic has led to concerns about consequences for students' learning. So far, data to study this question have been limited. Here we evaluate the effect of school closures on primary school performance using exceptionally rich data from The Netherlands (n ≈ 350,000). We use the fact that national examinations took place before and after lockdown and compare progress during this period to the same period in the 3 previous years. The Netherlands underwent only a relatively short lockdown (8 wk) and features an equitable system of school funding and the world's highest rate of broadband access. Still, our results reveal a learning loss of about 3 percentile points or 0.08 standard deviations. The effect is equivalent to one-fifth of a school year, the same period that schools remained closed. Losses are up to 60% larger among students from less-educated homes, confirming worries about the uneven toll of the pandemic on children and families. Investigating mechanisms, we find that most of the effect reflects the cumulative impact of knowledge learned rather than transitory influences on the day of testing. Results remain robust when balancing on the estimated propensity of treatment and using maximum-entropy weights or with fixed-effects specifications that compare students within the same school and family. The findings imply that students made little or no progress while learning from home and suggest losses even larger in countries with weaker infrastructure or longer school closures.

Evaluating the Digital Health Experience for Patients in Primary Care: Mixed Methods Study.

BACKGROUND: The digital health divide for socioeconomic disadvantage describes a pattern in which patients considered socioeconomically disadvantaged, who are already marginalized through reduced access to face-to-face health care, are additionally hindered through less access to patient-initiated digital health. A comprehensive understanding of how patients with socioeconomic disadvantage access and experience digital health is essential for improving the digital health divide. Primary care patients, especially those with chronic disease, have experience of the stages of initial help seeking and self-management of their health, which renders them a key demographic for research on patient-initiated digital health access. OBJECTIVE: This study aims to provide comprehensive primary mixed methods data on the patient experience of barriers to digital health access, with a focus on the digital health divide. METHODS: We applied an exploratory mixed methods design to ensure that our survey was primarily shaped by the experiences of our interviewees. First, we qualitatively explored the experience of digital health for 19 patients with socioeconomic disadvantage and chronic disease and second, we quantitatively measured some of these findings by designing and administering a survey to 487 Australian general practice patients from 24 general practices. RESULTS: In our qualitative first phase, the key barriers found to accessing digital health included (1) strong patient preference for human-based health services; (2) low trust in digital health services; (3) high financial costs of necessary tools, maintenance, and repairs; (4) poor publicly available internet access options; (5) reduced capacity to engage due to increased life pressures; and (6) low self-efficacy and confidence in using digital health. In our quantitative second phase, 31% (151/487) of the survey participants were found to have never used a form of digital health, while 10.7% (52/487) were low- to medium-frequency users and 48.5% (236/487) were high-frequency users. High-frequency users were more likely to be interested in digital health and had higher self-efficacy. Low-frequency users were more likely to report difficulty affording the financial costs needed for digital access. CONCLUSIONS: While general digital interest, financial cost, and digital health literacy and empowerment are clear factors in digital health access in a broad primary care population, the digital health divide is also facilitated in part by a stepped series of complex and cumulative barriers. Genuinely improving digital health access for 1 cohort or even 1 person requires a series of multiple different interventions tailored to specific sequential barriers. Within primary care, patient-centered care that continues to recognize the complex individual needs of, and barriers facing, each patient should be part of addressing the digital health divide.

Age-related digital disparities, functional limitations, and social isolation: unraveling the grey digital divide between baby boomers and the silent generation in senior living facilities.

OBJECTIVES: The onset of the digital age has sparked a significant age-related digital divide, detrimentally affecting older adults. The age-related digital disparities and the gray digital divide between the Baby Boomers and the Silent Generation in senior living facilities remains an exigent issue. This study explored the lived experiences of older adults as they confront the challenges posed by age-related digital disparities inherent in the gray digital divide in senior living facilities. METHODS: In-depth, semi-structured interviews and observations were conducted with 28 older adults living in six senior living facilities in three urban locations. Moustakas's transcendental phenomenology was employed, and the Modified Stevick-Colaizzi-Keen method was used to analyze the data. RESULTS: This study identified six main themes: barriers to connectivity, digital literacy, generational-rooted perceptions, navigating technology with functional limitations, social isolation, and end-of-life planning. CONCLUSION: The gray digital divide disproportionately affects older adults in senior living facilities. The study emphasizes the need for tailored interventions and targeted support to address the specific needs of each cohort and reduce age-related disparities. Addressing these disparities has significant implications for academics, policy-makers, senior living accommodations, and technology developers.

Disparities in resource utilisation by families of children with cardiac conditions.

OBJECTIVES: There are limited data documenting sources of medical information that families use to learn about paediatric cardiac conditions. Our study aims to characterise these resources and to identify any disparities in resource utilisation. We hypothesise there are significant variations in the resources utilised by families from different educational and socio-economic backgrounds. METHODS: A survey evaluating what resources families use (websites, healthcare professionals, social media, etc.) to better understand paediatric cardiac conditions was administered to caretakers and paediatric patients at Morgan Stanley Children's Hospital. Patients with a prior diagnosis of CHD, cardiac arrhythmia, and/or heart failure were included. Caretakers' levels of education (fewer than 16 years vs. 16 years or more) and patients' medical insurance types (public vs. private) were compared with regard to the utilisation of resources. RESULTS: Surveys completed by 137 (91%) caretakers and 27 (90%) patients were analysed. Websites were utilised by 72% of caretakers and 56% of patients. Both private insurance and higher education were associated with greater reported utilisation of websites, healthcare professionals, and personal networks (by insurance p = 0.009, p = 0.001, p = 0.006; by education p = 0.022, p < 0.001, p = 0.018). They were also more likely to report use of electronic devices (such as a computer) compared to those with public medical insurance and fewer than 16 years of education (p < 0.001, p < 0.001, respectively). CONCLUSION: Both levels of education and insurance status are associated with the utilisation of informative resources and digital devices by families seeking to learn more about cardiac conditions in children.

Disparities in Telehealth Offer and Use among U.S. Adults: 2022 Health Information National Trends Survey.

Objective: Understanding the sources of telehealth disparities can inform efforts to ensure equity. This study examines disparities in telehealth offer and use to understand the role of health care providers in increasing telehealth access. Methods: This cross-sectional analysis of the 2022 Health Information National Trends Survey (n = 5,295) used survey-weighted proportions to characterize telehealth use and multivariable logistic regressions to test associations of sociodemographic and social determinants with (1) telehealth offer and (2) use among those offered the option. Results: Among U.S. adults, 57% were offered telehealth, 80% of whom used it. Technology difficulties and privacy concerns were barriers for 15%-20% of U.S. adults. Compared to telehealth users, most nonusers preferred in-person care (25% versus 84%). Age, education, geographic location, and broadband internet access were related to telehealth offer, whereas no significant disparities emerged in telehealth use. Conclusions: Telehealth use is widespread, but structural and provider-level engagement are needed to achieve equity.

Individual Patient Factors Associated with the Use of Physical or Digital Primary Care in Sweden.

Introduction: Little is known about factors that influence patients' choice to use physical or digital primary care. This study aimed to compare self-rated health, internet habits, and what patients deem important when choosing health care between users of physical and digital primary health care. Methods: We recruited 2,716 adults visiting one of six physical or four digital primary health care providers in Stockholm, Sweden, October 2020 to May 2021. Participants answered a questionnaire with questions about sociodemography, self-rated health, internet habits, and what they considered important when seeking care. We used logistic regression and estimated odds ratios (ORs) for choosing digital care. Results: Digital users considered themselves healthier and used the internet more, compared with physical users (p < 0.001). Competence of health care staff was the most important factor when seeking care to both physical and digital users (90% and 78%, respectively). Patients considering it important to avoid leaving home were more likely to seek digital care (OR 29.55, 95% confidence interval [CI] 12.65-69.06), while patients valuing continuity were more likely to seek physical care (OR 0.25, 95% CI 0.19-0.32). These factors were significant also when adjusting for self-rated health and sociodemographic characteristics. Conclusion: What patients considered important when seeking health care was associated with what type of care they sought. Patient preferences should be considered when planning health care to optimize resource allocation.

Assessment of a Digital Health Coordination Program to Mitigate Telehealth Access Disparities.

Objective: Patients with digital disparity experience challenges with utilizing and accessing virtual care. This study implemented a digital coordination program for patients in outpatient psychiatry. Methods: Clinicians referred patients to a digital health coordinator who provided training to enhance virtual access. Outcomes were patient sociodemographics, barriers to digital health care utilization, change in completed video visits, and clinician satisfaction. Results: The patient cohort included 44 patients with a mean age of 59.8, 75% female, 73% Caucasian, and 84% non-Hispanic. The median household income was less than $25,000. The most common barrier to completing a video visit was difficulty using Zoom. The proportion of completed to scheduled video visits increased in 27% of patients. In such patients, the mean increase in completed visits was 32%. A majority of referring providers (64%) reported increased meaningfulness of work. Conclusion: This pilot proactively identified disparities in virtual care access and mitigated digital literacy barriers, boosting meaningfulness of work for clinicians.

[Sequential mediating role of digital participation and health lifestyle in the relationship between socioeconomic status and depression of older adults].

OBJECTIVE: To explore the potential mechanisms of the relationship between socioeconomic status (SES) and depression of Chinese older adults through the mediating role of digital participation and health lifestyle. METHODS: Using the nationally representative data from the China Family Panel Studies in 2020, 4 846 participants aged 60 years and older were analyzed in our study. We explored the potential mechanisms of the relationship between SES and depression of Chinese older adults in the digital era through a chain multiple mediating effects model. The KHB (The Karlson, Holm, and Breen) method was used to analyze the mediating role of digital participation and health lifestyle and the proportion of mediating effect between the two was also calculated. A series of robustness tests were further conducted and the fit of the model was checked by structural equation modeling. RESULTS: The mean age of the 4 846 older adults included in this study was (68.20±5.07) years, 48.06% of whom were female and 51.94% were male. The KHB results showed that both digital participation and health lifestyle could mediate the relationship between SES and depression of older adults (P < 0.000 1) and the mediating role of health lifestyle accounted for a greater proportion than digital participation. And our study mainly found three potential pathways of SES and depression of older adults, including: (1) SES → digital participation → health lifestyle → depression, (2) SES → health lifestyle → depression, and (3) SES → depression. Structural equation modeling tests proved the overall fit of the model in this study. CONCLUSION: Our findings showed that in the digital age, in addition to the direct relationship between SES and depression of older adults, and the health lifestyle as a mediator between the relationship, there is also a sequential mediating role of digital participation and health lifestyle to reduce the risk of depression. The findings suggest that we should pay more attention to the probability of the digital divide exacerbating health inequalities and socioeconomic inequalities accumulation in the digital age and promote the co-progress of digital literacy and health literacy among older adults.

[Digital literacy as a key element in the digital transformation of health organizations]. / La alfabetización digital como elemento clave en la transformación digital de las organizaciones en salud.

In the last years, the digital transformation, has become a reality influencing organizational processes and advancing services for users. This transformation must align with WHO guidelines, addressing the needs of individuals globally and acknowledging Social Determinants of Health and emerging Digital Determinants of Health and the digital divide thas has been created. To accomplish this, the appropriate legislation and infrastructures are required. Correspondingly technology enables enhanced self-care and increased participation in decision-making across various levels, consequently, addressing the digital divide must not be an exception, and needs to include citizens, communities, entities, and professionals to work on how to diminish it and solve it. As a result of this national and supranational campaigns should formulate unified plans and strategies, that include training requirements and establishing programs for both professionals and users, highlighting the significance of incorporating digital knowledge on both groups.

Associations of Depression/Anxiety with Technology Use, Discontinued Use, and Nonuse in Older Adults.

OBJECTIVES: To examine correlates of the changes in technology use among older adults and the associations of depression/anxiety symptoms with technology use changes. METHODS: We used the 2019-2021 U.S. National Health and Aging Trends Study (N = 3,063; age 70+). We fitted multinomial logistic regression models to examine: (1) correlates of never use and discontinued use versus use of email/texting and the internet during the 3-year study period; and (2) associations of past-month depression/anxiety symptoms in 2021 with use and discontinued use versus never use of email/texting and social network site (SNS). RESULTS: The findings show age, socioeconomic, and health barriers to technology use. Email/texting and SNS use in 2021, compared to never use in all 3 years, was associated with a lower likelihood of moderate/severe depression/anxiety symptoms in 2021 (RRR = 0.54, 95% CI = 0.37-0.81 for email/texting use; RRR = 0.56, 95% CI = 0.33-0.97 for SNS use). Video calls with family/friends were not associated with depression/anxiety symptoms. CONCLUSIONS: The findings expand the existing knowledge base regarding potential impact of technology use on mental health beyond the early months of the COVID-19 pandemic. CLINICAL IMPLICATIONS: More concerted efforts are warranted to help older adults' technology uptake and continued use and to promote mental health benefits of technology use.

Can a "Pandemic Life Adaptation" Digital Technology Curriculum Reduce the Digital Disadvantage of Older Adults During COVID-19? An Intervention Study from Shanghai.

Older adults are at a digital disadvantage because of social stereotypes and a lack of social support; however, smartphones have become a necessary technology to cope with crises and daily life in China, especially during the pandemic. This study aimed to help marginalized older adults take on new tasks by developing digital technology education that used a framework of social cognitive theory in social work. The study followed a quasi-experimental design in which 153 elderly people were recruited from three community service centers; 90 of the participants received 6-weekly intervention. Intent-to-treat analysis, effect size calculations, and sensitivity analysis were conducted. The findings show that digital education significantly enhanced two domains of digital life adaptation abilities: general digital life adaptation abilities [g = .50, 95% CI (.70, 2.69)] and pandemic digital life adaptation abilities [g = .89, 95% CI (.96, 2.07)]. The intervention also improved three domains of digital self-efficacy: sharing and communication [g = .55, 95% CI (.04, .48)], verification [g = .34, 95% CI (.01, .59)], and influencing others [g = .53, 95% CI (.13, .77)]. The study showed that the new intervention approach reduced the harm to vulnerable older adults in the digital wave, especially during the pandemic.

Internet use and psychological wellbeing among older adults in England: a difference-in-differences analysis over the COVID-19 pandemic.

BACKGROUND: Longitudinal evidence on how Internet use affects the psychological wellbeing of older adults has been mixed. As policymakers invest in efforts to reduce the digital divide, it is important to have robust evidence on whether encouraging Internet use among older adults is beneficial, or potentially detrimental, to their wellbeing. METHODS: We observe depressive symptoms and loneliness of adults aged 50 + in the nationally representative English Longitudinal Study of Ageing, from before (2018/19) to during the coronavirus disease 2019 (COVID-19) pandemic (June/July and November/December 2020). Our quasi-experimental difference-in-differences strategy compares within-individual wellbeing changes between older adults who desired to use the Internet more but experienced barriers including lack of skills, access, and equipment, with regular Internet users who did not desire to use the Internet more. To reduce selection bias, we match both groups on demographic and socioeconomic characteristics that are predictive of Internet use. We assume that in the absence of COVID-19 - a period of increased reliance on the Internet - the wellbeing trajectories of both groups would have followed a common trend. RESULTS: Compared with matched controls (N = 2983), participants reporting barriers to Internet use (N = 802) experienced a greater increase in the likelihood of depressive symptoms from before to during the pandemic, but not worse loneliness levels. This effect was stronger for women, those aged above 65 years, and those from lower-income households. CONCLUSIONS: Besides enabling access to digital services, efforts to ensure older adults continue to be engaged members of an increasingly digital society could deliver returns in terms of a buffer against psychological distress.

Widening participation - recruitment methods in mental health randomised controlled trials: a qualitative study.

BACKGROUND: Barriers to mental health research participation are well documented including distrust of services and research; and stigma surrounding mental health. They can contribute to a lack of diversity amongst participants in mental health research, which threatens the generalisability of knowledge. Given the recent widespread use of the internet in medical research, this study aimed to explore the perspectives of key partners on the use of online (e.g. social media) and offline (e.g. in-person) recruitment as an approach to improving diversity in mental health randomised controlled trials (RCTs). METHODS: Face-to-face and online interviews/focus groups with researchers working in mental health and Patient and Public Involvement partners in the United Kingdom. Recordings were transcribed and analysed using a combination of inductive and deductive thematic analysis. RESULTS: Three focus groups and three interviews were conducted with a total N = 23 participants. Four overarching themes were identified: (1) recruitment reach; (2) Demographic factors that affect selection of recruitment method; (3) safety of technology, and; (4) practical challenges. Five main factors were identified that affect the choice of recruitment method: age, complexity of mental health problem and stigma, cultural and ethnicity differences and digital divide. The use of online methods was considered more accessible to people who may feel stigmatised by their mental health condition and with a benefit of reaching a wider population. However, a common view amongst participants was that online methods require closer data monitoring for quality of responders, are not fully secure and less trustworthy compared to offline methods that enable participants to build relationships with health providers. Funding, staff time and experience, organisational support, and technical issues such as spam or phishing emails were highlighted as practical challenges facing online recruitment. All participants agreed that using a hybrid approach tailored to the population under study is paramount. CONCLUSIONS: This study highlighted the importance of offering a flexible and multifaceted recruitment approach by integrating online with offline methods to support inclusivity and widening participation in mental health research. The findings will be used to develop considerations for researchers designing RCTs to improve recruitment in mental health research.

Multi-stakeholder perspectives regarding preferred modalities for mental health intervention delivered in the orthopedic clinic: a qualitative analysis.

BACKGROUND: Although depressive and anxious symptoms negatively impact musculoskeletal health and orthopedic outcomes, a gap remains in identifying modalities through which mental health intervention can realistically be delivered during orthopedic care. The purpose of this study was to understand orthopedic stakeholders' perceptions regarding the feasibility, acceptability, and usability of digital, printed, and in-person intervention modalities to address mental health as part of orthopedic care. METHODS: This single-center, qualitative study was conducted within a tertiary care orthopedic department. Semi-structured interviews were conducted between January and May 2022. Two stakeholder groups were interviewed using a purposive sampling approach until thematic saturation was reached. The first group included adult orthopedic patients who presented for management of ≥ 3 months of neck or back pain. The second group included early, mid, and late career orthopedic clinicians and support staff members. Stakeholders' interview responses were analyzed using deductive and inductive coding approaches followed by thematic analysis. Patients also performed usability testing of one digital and one printed mental health intervention. RESULTS: Patients included 30 adults out of 85 approached (mean (SD) age 59 [14] years, 21 (70%) women, 12 (40%) non-White). Clinical team stakeholders included 22 orthopedic clinicians and support staff members out of 25 approached (11 (50%) women, 6 (27%) non-White). Clinical team members perceived a digital mental health intervention to be feasible and scalable to implement, and many patients appreciated that the digital modality offered privacy, immediate access to resources, and the ability to engage during non-business hours. However, stakeholders also expressed that a printed mental health resource is still necessary to meet the needs of patients who prefer and/or can only engage with tangible, rather than digital, mental health resources. Many clinical team members expressed skepticism regarding the current feasibility of scalably incorporating in-person support from a mental health specialist into orthopedic care. CONCLUSIONS: Although digital intervention offers implementation-related advantages over printed and in-person mental health interventions, a subset of often underserved patients will not currently be reached using exclusively digital intervention. Future research should work to identify combinations of effective mental health interventions that provide equitable access for orthopedic patients. TRIAL REGISTRATION: Not applicable.

A digital divide in the COVID-19 pandemic: information exchange among older Medicare beneficiaries and stakeholders during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic resulted in unprecedented challenges for older adults. Medicare enrollment was already an overwhelming process for a high fraction of older adults pre-pandemic. Therefore, the purpose of this qualitative study was to gain understanding from community organizations and stakeholders about their pre-pandemic and during-pandemic experiences while adapting to continue offering insurance advice to seniors, what resources are available to seniors, and what needs to be done to help seniors make higher quality insurance choices in the Medicare program. In addition, we wanted to explore how the COVID-19 pandemic may have changed the ways that these stakeholders interacted with Medicare beneficiaries. METHODS: We employed a qualitative strategy to gain a deep understanding of the challenges that these organizations may have faced while offering advice/counseling to older adults. We accomplished this by interviewing a group of 30 stakeholders from different states. RESULTS: Every stakeholder mentioned that some older adults have difficulty making Medicare decisions, and 16 stakeholders mentioned that their system is complex and/or overwhelming for older adults. Twenty-three stakeholders mentioned that Medicare beneficiaries are often confused about Medicare, and this is more noticeable among new enrollees. With the onset of the pandemic, 22 of these organizations mentioned that they had to move to a virtual model in order to assist beneficiaries, especially at the beginning of the pandemic. However, older adults seeking advice/meetings have a strong preference for in-person meetings even during the pandemic. Given that the majority of the beneficiaries that these stakeholders serve may not have access to technology, it was difficult for some of them to smoothly transition to a virtual environment. With Medicare counseling moving to virtual or telephone methods, stakeholders discussed that many beneficiaries had difficulty utilizing these options in a variety of ways. CONCLUSIONS: Findings from our interviews with stakeholders provided information regarding experiences providing Medicare counseling pre- and during-COVID-19 pandemic. Some of the barriers faced by older adults included a complex and overwhelming system, a strong preference for in-person meetings among beneficiaries, challenges with technology, and an increased risk of information overload and misinformation. While bias may exist within the study and sample, given that technology-savvy beneficiaries may not seek help from organizations our study participants work in, they show how the current Medicare system may impact vulnerable older adults who may need support with access to high-speed internet and digital literacy.